National Council for Behavioral Health Trauma-Informed Learning Communities

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1 www. TheNationalCouncil. org National Council for Behavioral Health Trauma-Informed Learning Communities Domain 1: Screening and Assessment September 11, 2017

2 Today s Presenters Cheryl Sharp, MSW, MWT Tony Salerno, PhD Reba Smith, MS

3 Webinar Agenda What is it and why do we do it? Questions to consider about how we do it Clinical vs. non clinical Screening for Resilience ACEs Questions for discussion Lack of effective interventions Negative impact of screening

History of the Work J. L. Herman. Trauma and Recovery, 1992. M. Harris, 2001.

5 History of the Work J. L. Herman. Trauma and Recovery, M. Harris, 2001.Using Trauma Theory to Design Service Systems: New Directions for Mental Health Services, Num. 89., National Council OSA

6 Everything is Everything Safety: Physical, Social/Emotional, Psychological Timing of screening and assessment Opportunity to revisit Staff understanding of trauma and the impact on the brain Treatment: Clinical decision tree Services available in TIC Environment

7 What is Trauma-Informed Screening & Assessment? Screening - brief, focused inquiry to determine an individual s Experience of traumatic events or current events that might be traumatizing Experiencing of invasive thoughts, feelings or behaviors associated with trauma Assessment - more in-depth exploration of the nature and severity of the traumatic events and the consequences on a person s life including current distressing symptoms

8 Why is Trauma-Informed Screening & Assessment Important? Universal trauma screening and specific trauma assessment methods are necessary to developing collaborative relationships with trauma survivors and offering appropriate services (Harris & Fallot, 2001) Necessary in order to avoid retraumatization, honoring the dictum: Above all, Do No Harm Sets the stage for building resilience, recognition of a survivors strengths and builds a healing alliance

9 The Underlying Rationale for Universal Exploration of Adverse life events The prevalence of adverse life events is particularly high in behavioral health settings Since everyone is likely to use primary care at some time, health centers will be treating individuals with adverse life events You usually can t determine the presence and impact of adverse life events from direct observation Most people will not spontaneously disclose adverse life events It is common for people with adverse life events to not make a connection between those events and current disappointments and difficulties The cumulative effects of numerous adverse life events is associated with a broad range of physical, emotional and substance use problems. You can t help if you don t know!!

10 Rationale for exploring the presence of adverse life events We, along with most health care and human service systems, do not routinely and comprehensively inquire about the trauma that may have been or currently experienced by our clients We can make mistakes when we don t fully understanding the role that trauma may be playing in the problems and disappointments of our clients.

11 Why exploring adverse life events is important: Sample of consumer perspectives There were so many doctors and nurses and social workers in your life asking you about the same thing, mental, mental, mental, but not asking you why. There was an assumption that I had a mental illness and because I wasn t saying anything about my abuse I d suffered, no-one knew. My life went haywire from thereon in I just wished they would have said: What happened to you? What happened? But they didn t. (Lothioan & Read, 2002)

12 Consequences of Failing to Screen and Assess for Trauma Many users of mental health services are upset at not being asked about abuse (Lothioan & Read, 2002) Inhibiting or holding back one s thoughts, feelings and behaviors is associated with toxic stress Not to inquire may further re-victimize the client (Doob,1992)

13 3 Big Questions 1. How do we find out if a person has experienced adverse life events? 2. How do we find out if these adverse life event experiences are contributing to the person s current mental health, substance use and/or physical health difficulties? 3. If we find out that adverse life events are contributing factors, what to do?

14 1. How do we find out if a person has experienced adverse life events? Formal and standardized screening for adverse life events usually in the form of psychometric surveys, scales or checklists. Expanded questions added to an existing psychosocial, medical history, mental status or functional assessment at intake or periodic treatment reviews. Interactive Interview: set of questions designed to engage the person in a conversation about family background, resource insufficiency, difficult life circumstances may be structured or as part of the ongoing clinical process designed to identify problem areas, set goals, select best treatment approaches and make informed decision

15 Is Self-Report Reliable? Self-report is generally an accurate method of obtaining psychiatric and medical history, including among trauma survivors (Fergusson et al., 2000; Wilsnack et al., 2002) People with schizophrenia and other psychoses have been found to report accurate histories (Read & Ross, 2003; Mueser et al., 2001; Whitfield, 2005)

16 2. How do we find out if these adverse experiences are contributing to the person s current mental health, substance use and/or physical health difficulties? Formal and standardized screening for the presence of symptoms often associated with traumatic life events (e.g., PTSD, depression, anxiety, suicidal thoughts, diffuse somatic complaints). These types of screening are usually in the form of psychometric surveys, scales, checklists. Interactive Interview: set of questions designed to engage the person in a conversation about physical, emotional and substance use problems and symptoms may include the person s perception of the relationship between adverse life events and problem areas Process may include assessing protective or resiliency factors as well

17 Polling Question #1 Which of the following best describes how you go about understanding a person s experience with adverse life events. We don t have a routine way of doing this. We use a standardized screening tool We include questions about adverse life events as part of intake and/or periodic reviews. We learn about adverse life events through the clinical process (up to the helper)

18 Polling Question #2 Which of the following best describes how you go about understanding the impact of adverse life events on a person s physical, emotional and substance use problems We don t have a routine way of doing this. We use a standardized symptom assessment tool(e.g., PTSD, PHQ-9, a symptom checklist) We include interview questions about symptoms such as PTSD as part of intake and/or periodic reviews. We learn about the impact of adverse life events through the clinical process (up to the helper)

19 Screening and Assessment Best Practices: Questions to Consider Is the person informed about why we are asking about adverse life events? (educating the client is key) Is the person reassured that they are invited to share this information in a way that respects one s comfort and need for control? Does the screener/assessor take into account the person s cultural/religious background? ( e.g., What the term trauma means?) Is there a procedure in place to re-engage or re-assess at other times during the treatment process? Does the assessment process lead to a review of the person s diagnosis when trauma is playing an important role? Do the assessment findings contribute to the service planning process?

20 Creating transparency, respecting preferences and promoting safety in the screening and assessment process Be clear about the steps and process of assessment (e.g. I would like to ask you some questions about.) Be clear about the reason for the questions Example of one approach to informing a client We have found that many people who come here for services have experienced things that were very difficult either as children or as adults. Because this can have such an important impact on a person s life, we ask everyone about whether they have ever been a victim of violence, abuse or neglect.

21 3. If we find out that adverse life events are contributing factors, what to do? Should we screen and assess for trauma related experiences and consequences if we don t have trauma specific specialized treatment providers? What type and level of training and experience would be enough? Maybe it is best to not inquire until we have quality treatment options? What do you think?

22 Discussion

23 Clinical Settings Universal precautions Universal assessment Safe conversations Trauma education usually within context of therapeutic relationship Strengths based Non-clinical Settings Universal precautions Part of intake/eligibility criteria Safe conversations Applicable trauma education with persons served Strengths based

24 The Power of ACEs The impact of ACEs can now only be ignored as a matter of conscious choice. With this information comes the responsibility to use it. (Anda and Brown, 2010, CDC)

25 Discussion are we discussing here? Reba you noted the discussion will start with the next question ACE as screening tool? Lack of effective interventions Negative impact of screening

26 ACE Questionnaire Research tool Not validated for clinical use Questions embedded in medical questionnaire Should not be used for screening Should not become part of clinical record

27 Interventions it is not at all clear that we have evidence based interventions for high ACE scores, and certainly the protocols for packaging such information into a rigorous intervention are still in the early stages of development. ---Finkelhor, D., Child Abuse & Neglect (2017), Resources Consider Trauma treatment options Competence of practitioners Accessibility of trauma treatment to those you are screening

28 Impact of Screening ACE screening has a number of such possible negative effects that need to be clearly investigated before launching a widespread screening program. For example, ACE screening may seem intrusive and discomforting for patients, could add to a sense of stigma, and may possibly disrupt health care relationships Finkelhor, D., Child Abuse & Neglect (2017), 6 Consider Are we screening in a trauma sensitive manner? Are we considering the timing of the screening? Research indicates that people want to talk to their providers about their experiences but will not bring it up themselves.

29 Screen for Resilience? Traditional assessment Diagnosis that aligns with trauma exposure Developmentally appropriate Based in current neurobiology Bio-psycho-social Resilience assessment Could it be an add-on? An opportunity to educate Potential for focus on prevention in addition to intervention Can highlight protective factors Provides hope

International journal of behavioral medicine, 15(3), 194-200. Liebenberg, L., Ungar, M., and Van de Vijver, F. R. R. (2012).

30 Resilience Scales Smith, B. W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P., & Bernard, J. (2008). The brief resilience scale: assessing the ability to bounce back. International journal of behavioral medicine, 15(3), Liebenberg, L., Ungar, M., and Van de Vijver, F. R. R. (2012). Validation of the Child and Youth Resilience Measure-28 (CYRM-28) Among Canadian Youth with Complex Needs. Research on Social Work Practice, 22(2), DOI: /

31 Screening and Assessment Resources National Council TIC website - Trauma Measures National Center for Post Traumatic Disorder (NCPTSD) Veteran s Administration SAMHSA Disaster Technical Assistance Center (DTAC) SAMHSA s Tip 57 Trauma-Informed Care in Behavioral Health Services, Appendix D Screening and Assessment Instruments Behavioral-Health-Services/SMA National Center for Trauma-Informed Care (NCTIC) National Child Traumatic Stress Network (NCTSN)

32 Contact Information Cheryl Sharp Reba Smith Tony Salerno

Willis O. Garrison, M.S Kenneth Tye, PH.D.

Willis O. Garrison, M.S Kenneth Tye, PH.D. More than 1 in 3 women (35.6%) and more than 1 in 4 men (28.5%) in the United States have experienced rape, physical violence, and/or stalking by an intimate